DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/148

Date of Institution : 23.02.2018/29.11.2021

Date of Decision : 04.07.2022

Mr. Satish Kumar s/o Sh. Ashok Kumar R/o Adda Amarkot, Tarn Taran.    …Complainant

Versus

Star Health and Allied Insurance Company Limited Through its Chairman/Managing Director/Principal Officer Through its Branch Office District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager. 

…Opposite Party

Complaint U/S 12 and 13 of The Consumer Protection Act

Present: Sh. Deepinder Singh Adv counsel for complainant.

Sh. RP Singh Adv counsel for the opposite party. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg  : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 12 and 13 of the Consumer Protection Act against Star Health and Allied Insurance Company Limited, New Delhi. (in short the opposite party). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant got Health Benefit mediclaim insurance for himself and his family from opposite party covering the risk period 25.1.2017 to 24.1.2018. The complainant fell ill on 18.4.2017 and taken to Nayyar Heart Institute and Super Speciality Hospital, Amritsar from 18.4.2017 to 21.4.2017 and treatment cost of the said hospitalization came to Rs. 2,60,296/-. The opposite party was informed about the said hospitalization and the treatment taken thereof as the said policy was issued on cashless basis and sum insured for medical benefit is for Rs. 5 lacs. The opposite party instead of making the said complete payment transferred the amount of Rs. 1,55,720/- in the account of the complainant. The complainant thereafter requested many times to make the balance payment of Rs. 1,04,576/- but the opposite party has not made any payment. No policy conditions were ever conveyed to the complainant and only cover note was issued to him. The act of the opposite party is deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to pay  the amount of Rs. 1,04,576/- alongwith interest at the rate of 12% per annum from 21.4.2017 till realization. 

2) To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment. 

3) To pay adequate litigation expenses.

4) Any other relief to which the complainant is found entitled. 

3. Upon notice of this complaint, the opposite party filed written statement taking preliminary objections that the complainant has concealed material facts from this Commission. He availed Family Health Optima Insurance Plan vide policy No. P/211111/01/2017/007386 for the period from 25.1.2017 to 24.1.2018 covering complainant himself, Mamta Rani spouse, Hanish Kumar and Rahul Kumar dependant children for the sum insured of Rs. 5,00,000/-. The terms and conditions were duly explained to the complainant at the time of proposing policy and same was served upon the complainant alongwith policy schedule. The insured was admitted in Nayyar Heart Institute and Super Specialty  on 18.4.2017 for the treatment of CAD-ACS and raised pre authorization request for cashless treatment and same was denied vide letter dated 19.4.2017 stating that patient present with CAD. Serial ECGs were not provided despite queries and moreover CAG reveals multi vessel disease pointing to long standing condition. Subsequently, the insurred submitted claim records for reimbursement of medical expenses and claim was authorized for Rs. 1,55,720/- against the total bill of Rs. 2,60,296/- and paid on 28.7.2017. Thereafter, the insured submitted a representation for reconsideration of the balance amount and claim was once again reviewed and paid Rs. 8,560/- on 28.9.2017 and opposite party paid Rs. 1,64,280/- to the complainant and there was deduction of Rs. 96,016/- on the grounds that.-

a) Angiography and Angioplasty done in the same sittings hence angiography 50% of the total only payable. Hence deducted Rs. 54,720/-.

b) Expenses reasonable and necessarily incurred towards procedure charges is Rs. 25,000/- only hence deducted Rs. 15,000/-. 

c) As per available documents no details for the usage of Inj. Aggriblock. Hence deducted Rs. 26,000/-.

d) Discount given by the hospital is not payable. Hence deducted Rs. 160/-.

The complainant has no locus standi to file the present complaint.

4. On merits, the opposite party submitted the same submissions as mentioned in the preliminary objections so there is no need to repeat the same. The terms and conditions of the policy served alongwith the policy schedule. There is no deficiency in service and unfair trade practice on the part of the opposite party. Lastly, the opposite party prayed for the dismissal of the present complaint.  

5. In support of his complaint, the complainant tendered into evidence his affidavit Ex.C-1, copy of policy Ex.C-2, copy of discharge card Ex.C-3 and closed the evidence. 

6. To rebut the case of the complainant, the opposite party   tendered in evidence affidavit of Rajiv Jain Ex.OP-1/1, copy of authority letter Ex.OP-1/2, copy of policy Ex.OP-1/3, copy of terms and conditions Ex.OP-1/4 and closed the evidence.  

7. We have heard the learned counsel for the parties and gone through the record on the file. 

8. The opposite party admitted all the contents regarding purchase of policy, validity of policy, sum insured and treatment taken by the complainant from Nayyar Heart Institute and Super Specialty Hospital, Amritsar. The only dispute between the parties is regarding the quantum of claim given by the opposite party to the complainant. The complainant admitted in his complaint that the opposite party has transferred the amount of Rs. 1,55,720/- in his account on account of insurance claim with regard to the expenses on the treatment of the complainant. The opposite party submitted in their written version that have reconsidered the claim and paid Rs. 8,560/- more to the complainant totaling Rs. 1,64,280/- to the complainant, which was also not denied by the complainant by filing any rejoinder or in his evidence. 

9. The opposite party submitted in their written version that they have deducted Rs. 96,016/- from the total claim of Rs. 2,60,296/-. They mentioned that they have deducted this amount on these grounds.-

a) Angiography and Angioplasty done in the same sittings hence angiography 50% of the total only payable. Hence deducted Rs. 54,720/-.

b) Expenses reasonable and necessarily incurred towards procedure charges is Rs. 25,000/- only hence deducted Rs. 15,000/-. 

c) As per available documents no details for the usage of Inj. Aggriblock. Hence deducted Rs. 26,000/-.

d) Discount given by the hospital is not payable. Hence deducted Rs. 160/-.

The opposite party deducted the amount of Rs. 54,720/- on account of Angiography and Angioplasty done in the same sittings hence angiography 50% of the total only payable. But opposite party has not produced any document vide which it established that the Angiography and Angioplasty done in the same sittings and also failed to produce any evidence to prove that both the procedures are not possible in the same sitting. Rest deductions were also not reasonable as the complainant had submitted the entire medical bills with the opposite party which was charged by the hospital. The opposite party wrongly deducted amount of Rs. 96,016/- from the medical bills of the complainant which is not justified and unreasonable. The opposite parties made the above mentioned deductions from the claim of the complainant but they have not tendered any document in their evidence vide which they have made these deductions. In this way the opposite party failed to rebut the case of the complainant with any convincing and reliable evidence and act of the opposite party is deficiency in service and unfair trade practice. 

10. In view of the above discussion, present complaint is partly allowed and opposite party is directed to pay the amount of Rs. 96,016/- to the complainant on account of balance amount of insurance claim alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite party is also directed to pay Rs. 3,300/- to the complainant as compensation for mental tension and harassment and Rs. 2,200/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        4th Day of July 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member